leishmaniasis ltc glenn wortmann, md associate program director, id fellowship infectious diseases...
TRANSCRIPT
LeishmaniasisLeishmaniasis
LTC Glenn Wortmann, MDAssociate Program Director, ID
FellowshipInfectious Diseases Service
Walter Reed Army Medical Center
LeishmaniasisLeishmaniasisObjectivesObjectives
Define Leishmaniasis
Describe the clinical presentation
Describe diagnostic procedures
Discuss available treatments for Leishmaniasis
LeishmaniasisLeishmaniasis
Group of diseases caused by infection with one of the protozoan parasites of the genus Leishmania
Designated one of the five most important diseases worldwide by the World Health Organization
20 million people infected worldwide
Geographic DistributionGeographic DistributionCutaneous DiseaseCutaneous Disease
Geographic DistributionGeographic DistributionVisceral DiseaseVisceral Disease
Life CycleLife Cycle
Copyright: TDR/Wellcome Trust
The VectorThe Vector
Courtesy of Dr. Ed Rowton, WRAIR
Clinical PresentationClinical Presentation
Cutaneous disease
Mucocutaneous leishmaniasis (Espundia)
Visceral disease (Kala-azar)
Localized Cutaneous Localized Cutaneous LeishmaniasisLeishmaniasis
Baghdad boil, Aleppo evil, Chiclero’s ulcer
Commonly presents as a non-healing ulcer
Incubation period ~40 days, but can range from days to a year
Cutaneous LeishmaniasisCutaneous Leishmaniasis
“In some cities infection is so common and so inevitable that normal children are expected to have the disease soon after they begin playing outdoors, and visitors seldom escape a sore as a souvenir. Since one attack gives immunity, Oriental sores appearing on an adult person in Baghdad brands him as a new arrival…”
Introduction to Parasitology, 1944
Number of OEF/OIF PatientsNumber of OEF/OIF Patients
0
10
20
30
40
50
60
70
80
90
April May June July August September October November December
Localized Cutaneous Localized Cutaneous LeishmaniasisLeishmaniasis
Localized Cutaneous Localized Cutaneous Leishmaniasis (cont.)Leishmaniasis (cont.)
Localized Cutaneous Localized Cutaneous Leishmaniasis (cont.)Leishmaniasis (cont.)
Localized Cutaneous Localized Cutaneous Leishmaniasis (cont.)Leishmaniasis (cont.)
Mucocutaneous LeishmaniasisMucocutaneous Leishmaniasis
Espundia
Most commonly reported in the New World with L. braziliensis and L. panamensis
1-3% of patients of all infected patients
EspundiaEspundia
Visceral LeishmaniasisVisceral Leishmaniasis
Kala-azar (Hindi for black sickness)
Fever
Enlarged liver and spleen
Anemia
Usually affects children
Increasingly reported in HIV patients
Visceral Leishmaniasis (cont.)Visceral Leishmaniasis (cont.)
DiagnosisDiagnosis
Cutaneous Disease Tissue sample (scraping, aspirate or
punch biopsy) for smear and culture – Sensitivity 75-90%– PCR
Visceral Disease Bone marrow biopsy or splenic aspirate
for smear and culture Serology (rk39, various ELISAs) PCR
Diagnosis HistopathologyDiagnosis Histopathology
Diagnosis Histopathology Diagnosis Histopathology (cont.)(cont.)
Diagnosis CultureDiagnosis Culture
Treatment-Cutaneous DiseaseTreatment-Cutaneous Disease
Most lesions go away in 5-6 months even without therapy
Local therapy (freezing, burning) for small lesions
Fluconazole once a day for 6 weeks ~80% effective at 3 months (versus 34%
in the placebo group)
Treatment-Cutaneous Disease Treatment-Cutaneous Disease (cont.)(cont.)
Sodium stibogluconate (Pentostam)
Not licensed by the FDA
Extensively used in other countries
20mg/kg/d IV for 10-20 days
>90% cure
Elevations in pancreas enzymes (97%),
joint pains (58%) and liver irritation (67%)
Treatment-Visceral DiseaseTreatment-Visceral Disease
AmBisome (liposomal amphotericin)
3mg/kg/d on days 1-5, 14 and 21
Only drug approved by the FDA
Pentostam
20mg/kg/d for 28 days
SummarySummary
Most likely presentation of leishmaniasis in a returning soldier would be cutaneous leishmaniasis
Chief complaint: non-healing skin lesion
Summary (cont.)Summary (cont.)
Suggest empiric routine care (antibiotics, wound care)
If no improvement after 2 weeks, then refer to WRAMC for evaluation
WRAMC assets: Diagnosis
– AFIP (Geographic Infections Branch)– WRAIR (Leishmania culture and PCR)
Treatment– IND for Pentostam
Infectious Disease Clinic, WRAMC 202-782-6740
DoD Deployment Health Clinical Center Walter Reed Army Medical CenterBuilding 2, Room 3G046900 Georgia Ave, NWWashington, DC 20307-5001
E-mail: [email protected]: www.PDHealth.mil
DoD Deployment Health Clinical Center Walter Reed Army Medical CenterBuilding 2, Room 3G046900 Georgia Ave, NWWashington, DC 20307-5001
E-mail: [email protected]: www.PDHealth.mil
Provider Helpline1-866-559-1627
Questions, Information,AssistanceQuestions, Information,Assistance
Patient Helpline1-800-796-9699
202-782-6563DSN:662